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By: Bertram G. Katzung MD, PhD

• Professor Emeritus, Department of Cellular & Molecular Pharmacology, University of California, San Francisco

http://cmp.ucsf.edu/faculty/bertram-katzung

This suggests that mechanisms other than womens employment can also have an impact on fertility discount 5g elocon fast delivery skin care greenville sc. For example elocon 5g online skin care wholesale, parents with more education may be better able to guide their childrens studies generic 5g elocon visa acne active, thus preparing them for post-secondary education generic elocon 5g line skin care 7, better jobs, and higher incomes, or the family may have more fnancial resources for a parent (usually the mother) to remain at home to raise the children, than those less-educated. In this case, parents with more education would want to have fewer children and invest more in their care. A study on the impact of womens education in India points out that, during that countrys �green revolution,� a time of rapid growth in agricultural production during the 1960s and 1970s, literate women commanded a premium dowry in the marriage market even when the return to female education in the labor market was not observed [9]. Educated men sought to marry educated women because of the higher quality care such wives would provide to any future children. Findings show that children with literate mothers studied for more hours than those whose mothers were illiterate. The authors concluded that the demand for schooled wives, during that period, was mainly due to the potential returns to these women raising better-educated children at home rather than returns to their employment in the labor market. Other arguments for the impact of womens education on fertility are the role these womens incomes play in improving their families economic prospects, and the improved social status that comes with higher education. For a household in a traditional agricultural economy, children are an important source of labor. However, as households of women with more education tend to earn higher incomes, they would have less need to rely on children fnancially. Also, in patriarchal societies, sons are valued more than daughters because they bring their parents a higher social status and are often responsible for taking care of them. In the absence of technology that screens fetuses, the preference for sons often leads to an increase in fertility. However, women with higher education tend to exhibit a weaker preference for sons than less-educated women, due to their fnancial independence and awareness of gender equality. Cost of birth control As long as there is a gap between the maximum number of achievable births and the desired number of children, a couple has an incentive to control birth. Better-educated women are more likely to be aware of modern contraceptives and to adopt new birth-control methods; their education may also help to improve their bargaining power with their husbands, thereby earning them consent to use contraception in the context of developing countries. Figure 3 compares two education groups and shows that an increase in the use of modern contraceptives by 20 percentage points is associated with a decrease in fertility by the same amount. This observation does not confrm the importance of obstacles to birth control, such as a lack of access to a family planning clinic, since womens education both increases the incentive to use contraception and improves knowledge on where to get it and how to use it. The case of Indonesia, from the 1970s to the 1990s, offers additional evidence for the role of education in the adoption of contraceptives [10]. While fertility declined among women of all education levels, it fell much faster among better-educated women. It is possible that these women benefted more from a family planning program that was implemented in 1971 and extended to villages, nationally, over the following decade. One issue was that womens fertility behavior may have been related to the location of a family planning clinic. To address this problem, the fertility rates of women in the same village were compared before and after the family planning clinic was set up. It was found that when women had post-primary education and a family planning clinic nearby, the probability of having a second birth was reduced by 12. These results imply that the effect of education through a family planning program explains three quarters of the total change in the fertility of women with post-primary education, over time. Primary level education helped these women lower their fertility, mainly through increasing their knowledge of contraceptive availability. However, it is unclear whether education enabled these women to have better access to new information, enhanced their ability to learn new technology or improved their bargaining power in the household. Contrary to the above fnding, one study presents a case wherein access to birth control benefted uneducated women more than educated women [11]. The study compared fertility behavior immediately before and after the liberalization, and found that fertility decreased by 30% within six months of the policy change. Further, the fertility differential between women with more than primary education and relatively less-educated women decreased by an average of 0. The lifting of the ban on birth control implies that all Romanian women had access to family planning. In other words, modern birth control was not new information, therefore the role of education in the adoption of contraceptives and abortion would be limited. In fact, it is reported that after the 1989 change in legislation uneducated women had, on average, 0. This may be viewed as uneducated women failing in family planning more often than educated women. Another argument is that womens higher education empowers them to make decisions on their fertility. In fact, womens empowerment could be the driving force for the effect of education on fertility [12]. In 1974, the Kenyan government introduced a family planning program; by the mid-1980s, knowledge of modern contraceptives was widespread. First, the reform narrowed the difference in educational attainment between women and their husbands, thereby increasing their bargaining power. In 1977, a family planning and maternal and child health program was implemented in a rural area and became one of the longest running social experiments among developing countries. The program covered 141 villages, half of which were to receive new services in addition to their regular government programs.

Diseases

• Double uterus-hemivagina-renal agenesis
• Penis agenesia
• Trigonocephaly bifid nose acral anomalies
• Congenital spherocytic anemia
• Mucopolysaccharidosis type II Hunter syndrome- mild form
• Hypomelanotic disorder
• EPP (erythropoietic protoporphyria)
• Glaucoma ecopia microspherophakia stiff joints short stature

Nephrol Dial Transplant 2007; University College London Hospital: the first fifty patients order 5g elocon skin care 50 year old woman. Hong Kong lupus erythematosus: A systematic review of off-label use in 188 cases cheap 5g elocon free shipping acne 2nd trimester. Long-term study of mycophenolate of the new biologicals and other emerging therapies elocon 5g low price skin care steps. Best Pract Res Clin mofetil as continuous induction and maintenance treatment for Rheumatol 2009; 23: 563�574 cheap 5g elocon overnight delivery acne 70. Systemic lupus with nephritis: a cyclophosphamide for induction treatment of lupus nephritis. Efficacy of enteric-coated azathioprine as maintenance therapy for lupus nephritis. N Engl J Med mycophenolate sodium in patients with resistant-type lupus nephritis: a 2011; 365: 1886�1895. Ann Rheum Dis cyclophosphamide delays the progression of chronic lesions more 2010; 69: 2083�2089. Predictors of relapse and end intravenous cyclophosphamide versus mycophenolate mofetil in the stage kidney disease in proliferative lupus nephritis: focus on children, induction therapy of proliferative lupus nephritis. Arthritis Rheum 2007; 56: in systemic lupus erythematosus: is there a need for more studies The pathogenesis and prognosis with increased renal and hematologic activity in patients with systemic of lupus nephritis: information from repeat renal biopsy. The clinical relevance levels are associated with concurrent flares in patients with systemic of a repeat biopsy in lupus nephritis flares. A 6-year prospective study in perceived stress and increased risk of flare in patients with lupus a cohort of 228 patients with lupus nephritis. Ann Rheum Dis 2009; 68: nephritis carrying the serotonin receptor 1A -1019 G allele. Prog Clin Biol inhibitors on the progression of nondiabetic renal disease: a meta Res 1990; 337: 301�307. 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Prenatally buy elocon 5g on line skin care 30s, the diagnosis may be made ultrasonographically by the demonstration of a cyst in the upper right side of the fetal abdomen order 5g elocon with amex skin care forum. The differential diagnosis includes enteric duplication cyst cheap elocon 5g with amex acne underwear, liver cysts generic elocon 5g free shipping skin care arbonne, situs inversus or duodenal atresia. The absence of polyhydramnios or peristalsis may help to differentiate the condition from bowel disorders. Postnatally, early diagnosis and removal of the cyst may avoid the development of biliary cirrhosis, portal hypertension, calculi formation or adenocarcinoma. Ovarian cysts Ovarian cysts are common and they may be found in up to one-third of newborns at autopsy, although they are usually small and asymptomatic. Fetal ovarian cysts are hormone-sensitive (human chorionic gonadotropin from the placenta) and tend to occur after 25 weeks of gestation; they are more common in diabetic or rhesus isoimmunized mothers as a result of placental hyperplasia. The majority of cysts are benign and resolve spontaneously in the neonatal period. Potential complications include development of ascites, torsion, infarction or rupture. Prenatally, the cysts are usually unilateral and unilocular, although, if the cyst undergoes torsion or hemorrhage, the appearance is complex or solid. Large ovarian cysts can be found in association with polyhydramnios, possibly as a consequence of compression of the bowel. Obstetric management should not be changed, unless an enormous or rapidly enlarging cyst is detected or there is associated polyhydramnios; in these cases, prenatal aspiration may be considered. A difficult differential diagnosis is from hydrometrocolpos, which also presents as a cystic or solid mass arising from the pelvis of a female fetus. Other genitourinary or gastrointestinal anomalies are common and include renal agenesis, polycystic kidneys, esophageal atresia, duodenal atresia and imperforate anus. Most cases are sporadic, although a few cases are genetic, such as the autosomal recessive McKusick�Kaufman syndrome with hydrometrocolpos, polydactyly and congenital heart disease. Mesenteric or omental cysts Mesenteric or omental cysts may represent obstructed lymphatic drainage or lymphatic hamartomas. Antenatally, the diagnosis is suggested by the finding of a multiseptate or unilocular, usually mid-line, cystic lesion of variable size; a solid appearance may be secondary to hemorrhage. Antenatal aspiration may be considered in cases of massive cysts resulting in thoracic compression. Postnatal management is conservative and surgery is reserved for cases with symptoms of bowel obstruction or acute abdominal pain following torsion or hemorrhage into a cyst. Complete excision of cysts may not be possible because of the proximity of major blood vessels and in up to 20% of cases there is recurrence after surgery. They appear as unilocular, intrahepatic cysts, and they are usually asymptomatic, although rarely may show complications such as infections or hemorrhages. In 30% of the cases of polycystic kidneys (adult type), asymptomatic hepatic cysts may be associated. Intestinal duplication cysts these are quite rare, and may be located along the entire gastrointestinal tract. Differential diagnosis includes other intra-abdominal cystic structures and also bronchogenic cysts, adenomatoid cystic malformation of the lung and pulmonary sequestration. Thickness of the muscular wall of the cysts and presence of peristalsis may facilitate the diagnosis. Anomalies of the umbilical vein Abnormalities of the umbilical vein, which are very rare, can be divided in three groups: (1) Persistence of the right umbilical vein with ductus venosus and presence or absence of left umbical vein; (2) Absence of the ductus venosus with extrahepatic insertion of the umbilical vein; and (3) Dilated umbilical vein with normal insertion. Normally, the umbilical vein enters the abdomen almost centrally at the level of the liver and courses on the left of the gallbladder. Persistence of the right umbilical vein is demonstrated by the fact that it is localized on the right of the gallbladder, bending towards the stomach. Color Doppler may help to diagnose these anomalies and may allow the differential diagnosis with other cystic abdominal lesions. Associated anomalies are frequent in anomalies of the first two groups and this influences the prognosis. These anomalies include cardiac, skeletal, gastrointestinal and urinary anomalies. The anomalies of the third group are rarely associated with other anomalies, and prognosis depends on the time at diagnosis and dimension of the varicosity. The renal echogenicity is high at 9 weeks but decreases with gestation; the adrenals appear as translucent structures with an echodense cortex. Longitudinal and transverse sections of the abdomen can be used to study the kidneys. In a longitudinal scan, kidneys appear as elliptical areas, while on transverse scan they appear as roundish structures at both sides of the spine. At 20 weeks, the kidneys show a hyperechoic capsule and the cortical area is slightly more echogenic than the medulla. With progressing gestation, fat tissue accumulates around the kidneys, enhancing the borders of the kidneys in contrast with the other splanchnic organs. At 26�28 weeks, renal pyramids can be detected, and the arcuate arteries can be seen pulsating in their proximity. Both the renal length and circumference increase with gestation, but the ratio of renal to abdominal circumference remains approximately 30% throughout pregnancy. The anteroposterior diameter of the renal pelvis should be < 5 mm at 15�19 weeks, < 6 mm at 20�29 weeks and < 8 mm at 30�40 weeks.

One typical and peculiar finding is the interruption of the inferior vena cava generic elocon 5g skin care market, with the lower portion of the body drained by the azygos vein 5g elocon visa acne gel prescription. Evaluation of the disposition of the abdominal organs is of special value for the sonographic diagnosis of fetal cardiosplenic syndromes cheap 5g elocon mastercard acne gel. In normal fetuses discount 5g elocon with amex cystic acne, a transverse section of the abdomen demonstrates the aorta on the left side and the inferior vena cava on the right; the stomach is to left and the portal sinus of the liver bends to the right, towards the gallbladder. In polysplenia, a typical finding is interruption of the inferior vena cava with azygous continuation (there is failure to visualize the inferior vena cava and a large venous vessel, the azygos vein, runs to the left and close to the spine and ascends into the upper thorax). Symmetry of the liver can be sonographically recognized in utero by the abnormal course of the portal circulation that does not display a clearly defined portal sinus bending to the right. The heterogeneous cardiac anomalies found in association with polysplenia are usually easily seen, but a detailed diagnosis often poses a challenge; in particular, assessment of connection between the pulmonary veins and the atrium (an element that has a major prognostic influence) can be extremely difficult. Associated anomalies include absence of the gallbladder, malrotation of the guts, duodenal atresia and hydrops. As in polysplenia, evaluation of the disposition of the abdominal organs is a major clue to the diagnosis. The spleen cannot be seen and the stomach is found in close contact with the thoracic wall. Cardiac malformations are severe, with a tendency towards a single structure replacing normal paired structures: single atrium, single atrioventricular valve, single ventricle and single great vessel, and are usually easily demonstrated. Diagnosis Cardiosplenic syndromes may be inferred by the abnormal disposition of the abdominal organs. Prognosis the outcome depends on the amount of cardiac anomalies, but it tends to be poor. Atrioventricular insufficiency and severe fetal bradycardia due to atrioventricular block may lead to intrauterine heart failure. Etiology Histological studies have shown these foci to be due to mineralization within a papillary muscle. In about 95% of cases they are located in the left ventricle and in 5% in the right ventricle; in 98% they are unilateral and 2% bilateral. Prognosis Echogenic foci are usually of no pathological significance and in more than 90% of cases they resolve by the third trimester or during pregnancy. However they are sometimes associated with cardiac defects and chromosomal abnormalities. For isolated hyperechogenic foci the risk for trisomy 21 may be three-times the background maternal age and gestation related risk. The diagnosis is made by passing an M-mode cursor through one atrium and one ventricle. Premature atrial contractions are spaced closer to the previous contraction than normally and may be transmitted to the ventricle or blocked. Premature ventricular contractions present in the same way but are not accompanied by an atrial contraction. Premature ventricular contractions are often followed by a compensatory pause due to the refractory state of the conduction system; the next conducted impulse arrives at twice the normal interval, and the continuity of the rhythm is not broken. Premature atrial contractions are usually followed by a non-compensatory pause; when the regular rhythm resumes, it is not synchronous with the rhythm before the extrasystole. The distance between the contraction that preceded the premature contraction and the one following it is not twice the distance between two normal contractions but a little shorter. Another approach to the sonographic diagnosis is to evaluate the waveforms obtained from the atrioventricular valves, hepatic vessels or inferior vena cava, which demonstrate pulsations corresponding to atrial and ventricular contractions. Premature contractions are benign, tend to disappear spontaneously in utero, and only rarely persist after birth. It has been suggested that in some cases there may be progression to tachyarrhythmia, but the risk if any is certainly very small. In the majority of cases the abnormal electrical impulse originates from the atria. Atrial tachyarrhythmia includes supraventricular tachycardia, atrial flutter and atrial fibrillation. Since atrial rhythms greater than 240 bpm are usually associated with varying degrees of atrioventricular block, the ventricular rate is usually reduced to 60 to 160 bpm. Supraventricular tachycardia is the most common form of tachyarrhythmia, and the ventricular response is 1:1. Supraventricular tachycardia may be due to an autonomous focus, in which case the rhythm is monotonous, or to a re-entry mechanism, in which case sudden conversion from an abnormal to a normal rhythm can be seen. Occasionally, atrioventricular block of high degree with ventricular bradycardia are seen. Atrial fibrillation is characterized by an atrial rate greater than 400 bpm and completely irregular ventricular rhythm, with constant variation of the distance between systole. Ventricular tachycardias are rare, and have typically a ventricular frequency of 200 bpm or less. Tachycardia is commonly associated with hydrops, as a consequence of low cardiac output. Diagnosis the heart rate, atrial and ventricular, can be analyzed by either M-mode sonography of the cardiac chambers or pulsed Doppler evaluation of atrioventricular inflows, hepatic veins and inferior vena cava. A heart rate of about 240 bpm with atrioventricular conduction of 1:1, is pathognomonic of supraventricular tachycardia. An atrial rate greater than 300 bpm with an atrioventricular response of 1:2 or less indicates atrial flutter. A very fast atrial rate with irregular ventricular response is indicative of atrial fibrillation.

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